Introduction

The Department of Health and NHS England have asked NICE to develop evidence-based guidelines on safe staffing, with a particular focus on nursing and midwifery staff, for England. This request followed the publication of the Francis report (2013) and the Keogh review (2013).

Focus of the guideline

This guideline makes recommendations on safe midwifery staffing requirements for maternity settings, based on the best available evidence. The guideline focuses on the pre-conception, antenatal, intrapartum and postnatal care provided by midwives in all maternity settings, including: at home, in the community, in day assessment units, in obstetric units, and in midwifery-led units (both alongside hospitals and free-standing).

The guideline recommendations are split into different sections:

  • Recommendations in section 1.1 are aimed at trust boards, senior management and commissioners, and identify organisational and managerial responsibilities to support safe midwifery staffing requirements.

  • Recommendations in section 1.2 are aimed at senior registered midwives (or other authorised people) who are responsible for setting the midwifery staffing establishment. They focus on the process for setting the staffing establishment and the factors that should be taken into account.

  • Recommendations in section 1.3 are aimed at senior registered midwives who are in charge of maternity services or shifts. They are about ensuring that the service or shift can respond to situations that may lead to an increased demand for midwives and to differences between the numbers of midwives needed and the numbers available.

  • Recommendations in section 1.4 are aimed at senior management and registered midwifery managers and are about monitoring whether safe midwifery staffing requirements are being met. This includes recommendations to review midwifery staffing establishments and adjust them if necessary.

For further information, see the scope for the guideline.

This guideline is for organisations that provide or commission services for NHS service users. It is aimed at policy decision makers, commissioners, trust boards, hospital managers, service managers, heads and directors of nursing and midwifery, midwives, and other healthcare professionals. It will also be of interest to regulators and the public.

In this guideline, the terms midwife and midwifery refer to registered midwives only. Maternity support workers or other staff working alongside midwives are not included in this definition.

Those responsible and accountable for staffing maternity services should take this guideline fully into account. However, this guideline does not override the need for, and importance of, using professional judgement to make decisions appropriate to the circumstances.

This guideline does not cover national or regional level workforce planning or recruitment, although its content may inform these areas.

This guideline does not address staffing requirements in relation to other staff groups such as maternity support workers, medical consultants, theatre nurses or allied health professionals, although we acknowledge that a multidisciplinary approach and the availability of other staff and healthcare professionals are an important part of safe staffing for maternity services. The guideline takes into account the impact of the availability of other staff groups on midwifery staffing requirements.

Toolkits to support this guideline

The guideline will also be of interest to people involved in developing evidence‑based toolkits for assessing and determining safe midwifery staffing requirements. For details of any toolkits that can help with implementing this guideline see tools and resources.

Staffing ratios

A minimum staffing ratio for women in established labour has been recommended in this guideline, based on the evidence available and the Safe Staffing Advisory Committee's knowledge and experience. The committee did not recommend staffing ratios for other areas of midwifery care. This was because of the local variation in how maternity services are configured and therefore variation in midwifery staffing requirements, and because of the lack of evidence to support setting midwife staffing ratios for other areas of care. Professional guidance, toolkits and other resources about midwifery staffing levels or ratios are available. However, there was a lack of evidence regarding the effectiveness of existing toolkits and resources for calculating safe midwifery staffing.

The committee's discussions about staffing ratios and toolkits are contained in the evidence to recommendations tables that are published alongside the guideline (see appendix 1). See the sections on gaps in the evidence on staffing ratios and research recommendations for further details.

Woman- and baby-centred care

Individually assessing the care needs of each woman and baby is paramount when making decisions about safe midwifery staffing requirements. The assessments should take into account individual preferences and the need for holistic care and contact time between the midwife and the woman and baby.

Women should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. Healthcare professionals and others responsible for assessing safe midwifery staffing requirements for maternity settings should also refer to NICE's guideline on patient experience in adult NHS services.

Women and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these.

Evidence to recommendations

When drafting these recommendations, the Safe Staffing Advisory Committee discussed evidence from the systematic reviews and an economic analysis report described in the section on the evidence. In some areas there was limited or no published evidence. In these cases, the committee considered whether it was possible to formulate a recommendation on the basis of their experience and expertise. The evidence to recommendations tables presented in appendix 1 detail the committee's considerations when drafting the recommendations.

The committee also identified a series of gaps in the evidence – please see the section on gaps in the evidence for further details.

When drafting the recommendations, the committee took into account:

  • whether there is a legal duty to apply the recommendation (for example, to be in line with health and safety legislation)

  • the strength and quality of the evidence base (for example, the risk of bias in the studies looked at, or the similarity of the populations covered)

  • the relative benefits and harms of taking (or not taking) the action

  • any equality considerations.

Strength of recommendations

Recommendations using directive language such as 'ensure', 'provide' and 'perform' are used to indicate the committee was confident that a course of action would lead to safe midwifery care.

If the quality of the evidence or the balance between benefits and harms means that more time should be taken to decide on the best course of action, the committee has used 'consider'.

Recommendations that an action 'must' or 'must not' be taken are usually included only if there is a legal duty (for example, to comply with health and safety regulations).